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r- SAN JOAOUIN COU~ PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEA_r DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EN 01 1$ COWNFAC) Revis 8/26/93 <br /> NEW FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE �-/ / INACTIVE <br /> Prior Owner - <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGES / DELETE <br /> OWNER FILE <br /> OWNER TD J� CASE 0 BILLING PARTY <br /> OWNER NAME hJ <br /> , OWNER HOME PHONE C ) <br /> OWNER DBA 4! r V�A O � OWNER MRK/BUS PH ( ) <br /> OWNER ADDRESS �ZC$p�' <br /> OWNER CITY I� r GCS STATE ZIP <br /> MAILING ADDRESS <br /> CARE OF <br /> CITY YI 71 C-;t4�0 STATE i - ZIP <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE- <br /> FACILITY 11) # �CJ S BILLING PARTY Y / <br /> OF EMIPLOYEES <br /> FACILITY HAME TRUST LANDS? T / A <br /> FACILITY ADDRESS (/ HOKE PH <br /> CROSS STREET BI15N PH C } <br /> CITY STATE ZIP <br /> Census --------- SO$ Dist Location Cc City Code ---------- <br /> iKAILING ADDRESS APN # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE CUST) <br /> THIRD PARTY BILLING INFORMATION <br /> NAME WORE PHONE ( ) <br /> MAILING ADDRESS BUSH PHONE ( ) <br /> CARE OF <br /> CITY STATE ZIP <br />